Physical Exam

Chest and Respiratory Inspection

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Video coming September 2026

How to Perform

With the patient breathing quietly, begin inspection with clothing in place. Observe the rate, depth, rhythm, and effort of breathing and any obvious asymmetry of chest-wall movement, accessory muscle use, cyanosis, or pursed-lip breathing. Lift or move the shirt as needed to inspect the chest shape and symmetry and to look for intercostal or supraclavicular retractions or paradoxical movement.

How to Interpret

Acidosis

Nasal flaring

Rule in

Somewhat helpful

Rule out

—

Evidence:Limited

Chronic Obstructive Pulmonary Disease

Barrel chest (visual impression of increased anteroposterior diameter)

Rule in

Somewhat helpful

Rule out

—

Evidence:Limited

Hoover sign

Rule in

Somewhat helpfulDerived CI

Rule out

Somewhat helpfulDerived CI

Evidence:Limited

Thoracic index (measured anteroposterior-to-lateral chest diameter ratio) ≥0.9

Rule in

Somewhat helpful

Rule out

—

Evidence:Limited

Accessory muscle use

Ejection Fraction Below 40%

Cheyne-Stokes respirations in a patient aged 80 or younger

Rule in

HelpfulDerived CI

Rule out

—

Evidence:Limited

Cheyne-Stokes respirations

Rule in

Helpful

Rule out

Not helpfulNo CI

Evidence:Limited

Respiratory Neuromuscular Weakness

Accessory muscle use in patients with ALS

Rule in

—

Rule out

InconclusiveNo CI, small study

Evidence:LimitedResearch in progress

References

Research in progress on one or more findings above; ratings may change.

Holleman DR Jr, Simel DL. Does the clinical examination predict airflow limitation? JAMA. 1995;273(4):313-319. doi:10.1001/jama.1995.03520280059041. PMID: 7815660.
de Mattos WL, Signori LGH, Borges FK, Bergamin JA, Machado V. Accuracy of clinical examination findings in the diagnosis of COPD. J Bras Pneumol. 2009;35(5):404-408. PMID: 19547847.
Garcia-Pachón E. Paradoxical movement of the lateral rib margin (Hoover sign) for detecting obstructive airway disease. Chest. 2002;122:651–655. PMID: 12171846.
Mattos WLLD, Signori LGH, Borges FK, Bergamin JA, Machado V. Accuracy of clinical examination findings in the diagnosis of COPD. J Bras Pneumol. 2009;35(5):404-408. PMID: 19547847.
Hull RD, Raskob GE, Carter CJ, Coates G, Gill GJ, Sackett DL, Hirsh J, Thompson M. Pulmonary embolism in outpatients with pleuritic chest pain. Arch Intern Med. 1988;148(4):838-844. PMID: 3355304.
Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17):1440-1445. PMID: 9356004.
Kalantri S, Joshi R, Lokhande T, Singh A, Morgan M, Colford JM Jr, Pai M. Accuracy and reliability of physical signs in the diagnosis of pleural effusion. Respir Med. 2007;101(3):431-438. doi:10.1016/j.rmed.2006.07.014. PMID: 16965906. Tabulated in: Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA. 2009;301(3):309-317. doi:10.1001/jama.2008.937. PMID: 19155458.
Lechtzin N, Wiener CM, Shade DM, Clawson L, Diette GB. Spirometry in the supine position improves the detection of diaphragmatic weakness in patients with amyotrophic lateral sclerosis. Chest. 2002;121(2):436-442. PMID: 11834654.
Zorrilla-Riveiro JG, Arnau-Bartes A, Rafat-Sellares R, Garcia-Perez D, Mas-Serra A, Fernandez-Fernandez R. Nasal flaring as a clinical sign of respiratory acidosis in patients with dyspnea. Am J Emerg Med. 2017;35(4):548-553. PMID: 28007319.
Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI, Herkner H, Gonano C, Weinstabl C, Kettner SC. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010;341:c5943. PMID: 21062875
Gilbert R, Ashutosh K, Auchincloss JH, Rana S, Peppi D. Prospective study of controlled oxygen therapy: poor prognosis of patients with asynchronous breathing. Chest. 1977;71(4):456-462. PMID: 856543
Mier-Jedrzejowicz A, Brophy C, Moxham J, Green M. Assessment of diaphragm weakness. Am Rev Respir Dis. 1988;137(4):877-883. PMID: 3354995
McGee SR. Cheyne-Stokes breathing and reduced ejection fraction. Am J Med. 2013;126(6):536-540. PMID: 23541375.
McGee S. Cheyne-Stokes breathing and reduced ejection fraction. Am J Med. 2013;126(6):536-540. PMID: 23541375.
Liu PY, Tsai KZ, Lin YP, et al. Prevalence and characteristics of mitral valve prolapse in military young adults in Taiwan of the CHIEF Heart Study. Sci Rep. 2021;11(1):2719. doi:10.1038/s41598-021-81648-z. PMID: 33526804.
Bickley LS, Szilagyi PG, Hoffman RM, Soriano RP. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA: Wolters Kluwer; 2021.
Swartz MH. Textbook of Physical Diagnosis: History and Examination. 9th ed. Philadelphia, PA: Elsevier; 2025.

Research last updated September 10, 2026.